Spontaneous biloma due to an intrahepatic cholangiocarcinoma: An extremely rare case report with long term survival and literature review

Cholangiocarcinomas are tumors that arise from the ductal epithelium of the intrahepatic or extra-hepatic bile ducts. Patients are usually asymptomatic or may present with weight loss, fatigue, loss of appetite and abdominal pain (intrahepatic cholangiocarcinomas) or jaundice (extra-hepatic cholangiocarcinomas). Subcapsular bile vessel rupture, due to intrahepatic cholangiocarcinoma, is an extremely rare clinical presentation, which is an emergent and potentially life-threatening complication. We report the case of a 79-year-old female patient suffering from an intrahepatic cholangiocarcinoma that completely obliterated the left main hepatic duct. This obstruction in intrahepatic bile flow had resulted in intraperitoneal rupture of subcapsular bile vessels (not infiltrated by the tumor) of the left liver lobe and formation of spontaneous biloma. The patient was admitted for acute abdominal pain. Computed tomography (CT) and Magnetic Resonance Imaging (MRI) revealed the tumor and an upper abdominal fluid collection. Since the patient was hemodynamically stable and afebrile, a CT-guided percutaneous aspiration of the collection was undertaken, showing a biloma. A left hepatectomy was performed two weeks later and today, sixty months since the incident, the patient enjoys good health, with no signs of local recurrence or distant metastases. Intraperitoneal rupture of bile ducts and subsequent spontaneous biloma formation, due to an intrahepatic cholangiocarcinoma which completely obstructed the left main hepatic duct, is a unique situation and this is the first time to be reported. Prompt surgical management can lead to successful treatment of this rare and difficult entity.

An inguinal hernia with cryptorchidism with a Leydig cell tumor in an elderly man: A case report

INTRODUCTION

Cryptorchidism is common in children but is rare in the elderly. It often presents with a constellation of signs and symptoms similar to routine inguinal hernias. We present the case of an elderly man with cryptorchidism containing a Leydig cell tumor and provide clinical insights.

PRESENTATION OF CASE

An-84-year old man was admitted with an incarcerated right lower quadrant hernia. Both testes were absent on palpation of the scrotum. After reduction of the hernia, computed tomography scan revealed a round lesion in the hernia sac, which was suspected to be the ectopic testis. Laparoscopic exploration was performed in combination with an open anterior approach. The hernia orifice was the right internal inguinal ring, and the inguinal canal was obliterated by adhesions because the spermatic cord did not pass through it. The ectopic testis was resected with the hernia sac, and the hernia repaired with a KUGEL™ patch (Bard, USA).

DISCUSSION

Laparoscopic exploration was useful to delineate the anatomy of this unusual inguinal hernia. The open anterior approach was necessary to dissect the ectopic testis and the hernia sac. Pathological findings revealed tumor cells with clear cytoplasm in the resected testis, diagnosed as a Leydig cell tumor.

CONCLUSION

The combination of laparoscopic and anterior approaches facilitated the surgical treatment of an unusual inguinal hernia with cryptorchidism. The resected ectopic testis should undergo thorough histopathologic examination.

A case report of unusual anatomical variation: externalisation of inferior alveolar nerve

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Incidence of permanent IAN damage ranges from 0.35% to 8.4%.

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Timely, accurate pre-operative visualisation of nerve is paramount in a safe clinical practice and reduces the risk of unnecessary litigations.

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CT imaging has better sensitivity and specificity in demonstrating nerve and tooth relationships compared to plain film radiographs.

Introduction

The risks of third molar surgery have been well documented with damage to the inferior alveolar nerve (IAN) being one of the largest concerns.

Presentation of case

This case report presents an impacted third molar with associated dentigerous cyst in which the IAN is externalised and runs along the lateral surface of the mandible.

Discussion

This is an extremely rare anatomical variation with most IANs lying inferior and lingually to third molars. This case reiterates the limitations of standard radiographic techniques such as the orthopantomogram (OPG).

Conslusion

We would advocate the use of cone beam computed tomography (CBCT) in cases which have adverse plain radiographic features to allow appropriate surgical planning.

Transverse testicular ectopia with scrotal hypospadias but without inguinal hernia - Case report of a rare association

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TTE associated with scrotal hypospadias but without inguinal hernia is an extremely rare anomaly and possibly has never been reported in literature.

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The diagnosis of TTE is usually considered when unilateral hernia and concurrent cryptorchidism of the contralateral side are present but it can also present without inguinal hernia as in our case.

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Presence of inguinal hernia should never be considered a prerequisite for a clinical diagnosis of TTE.

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In suspected cases, ultrasonographic evaluation, MRI of the pelvis and laparoscopy may be helpful in diagnosing this condition before surgery.

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Management is either trans-septal orchiopexy or extraperitoneal transposition orchiopexy.

Transverse testicular ectopia is an extremely rare anomaly, in which both the testis migrate towards the same hemiscrotum through the same inguinal canal. It is usually associated with other abnormalities such as persistent Mullerian duct syndrome, true hermaphroditism, inguinal hernia, pseudohermaphroditism, and scrotal anomalies; the association with inguinal hernia being the commonest. We, here, report a case of transverse testicular ectopia in a 12 years old boy having the ectopic testis in contralateral hemiscrotum without any inguinal hernia but having scrotal hypospadias with severe chordee. The diagnosis was made on clinical examination and confirmed on ultrasonography. Trans-septal orchiopexy was done for ectopic testis and hypospadias and chordee were managed by staged repair.

Bronchial mucoepidermoid carcinoma: A case report

INTRODUCTION

Bronchial localization of Mucoepidermoid carcinoma (MEC) is rare. The precise nature of these neoplasms is not yet clear and little is known on the histogenesis and pathogenesis of the disease. Here we present a case of a bronchial MEC with a detailed pathological, immunohistochemical, and molecular analysis.

PRESENTATION OF A CASE

A 46 years old Caucasian male patient was referred to our Unit for fever, non productive cough and dyspnea lasting for two months. The chest CT scan evidenced an 8-mm intraluminal lesion in the left main bronchus, in correspondence of the origin of the lingular segmental bronchus. Multiple biopsies were performed through bronchoscopy, and the diagnosis of a mucoepidermoid carcinoma of the lung was obtained. A left upper lobectomy was performed. The histopathological examination confirmed the preoperative diagnosis and stage (pT1N0M0). No further therapies were employed, given the stage of the disease. The patient is presently free of disease, approximately three years after surgery.

DISCUSSION

The treatment of MECs is usually surgical by traditional or sleeve lobectomy, performed with an open or video-assisted technique, with the aim of an R0 resection. In this stage the prognosis is excellent. Conversely, high grade tumors seems to be particularly aggressive, even more than other NSCLC.

CONCLUSIONS

Low grade type of Bronchial MEC, as our case, is often characterized by an optimal clinical management and prognosis. The lack of EGFR sensitizing mutations does not preclude the use of TKIs, which may be extremely useful in patients non responsive to other therapies.

Bilateral approach for thoracoscopic esophagectomy with lymph node dissection in the dorsal area of the thoracic aorta in patients with esophageal cancer: A report of two cases

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We presented two esophageal cancer patients performed thoracoscopic esophagectomy.

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These two cases have lymph node metastasis of dorsal area of thoracic aorta (DTA).

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We performed successfully underwent the dissection of lymph node of DTA.

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The bilateral thoracoscopic approach performedsafely in the prone position.

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The long-term outcome of lymphadenectomy in the DTA among esophageal cancer patients remain controversial.

Introduction

The incidence of lymph node metastasis in the dorsal area of the thoracic aorta (DTA) is relatively low in patients with esophageal cancer. It is difficult to approach the DTA using surgical procedures, such as an open thoracotomy and thoracoscopy in the left decubitus position.

Case presentation

Case 1: A 70-year-old man with esophageal cancer underwent thoracoscopic esophagectomy with mediastinal lymph node dissection via a right thoracoscopic approach, followed by lymphadenectomy in the DTA via left thoracoscopy in the prone position. Microscopic findings revealed two metastatic lymph nodes in the DTA. The definitive diagnosis was squamous cell carcinoma of the esophagus, and the pathological stage was T2N3M0 (Union for International Cancer Control [UICC], 7th edition). The patient showed lung metastasis 8 months after the surgery. Case 2: A 72-year-old man with esophageal cancer underwent esophagectomy via a bilateral approach in the prone position, using a similar procedure as in case 1. The definitive diagnosis was squamous cell carcinoma of the esophagus, and the pathological stage was T3N2M0. The patient showed a metastatic mediastinal lymph node 4 months after the surgery.

Conclusion

Bilateral thoracoscopic esophagectomy in the prone position can be safely performed, and it might be an alternative curative surgery for esophageal cancer. However, both our cases showed metastasis in the early postoperative period. The long-term outcome and significance of dissection of lymph nodes in the DTA in patients with esophageal cancer remains controversial. Further studies are required to establish the indications and efficacy of this therapeutic approach.

A case of IV degree on acute radiation dermatitis in China

This report investigates the nursing procedure of a case of adjuvant therapy of rectal cancer on IV degree of acute radiation dermatitis patients in the penis and scrotum junction. The lesion degree gradually increased. Fixation of the dressing was difficult in the penis and scrotum junction. The concept of wet healing with new dressings was used in patient. The silver ion dressings were used in inhibiting infection, and the wound was covered by the rimmed foam dressings. When it comes to the shaping period, water gel transparent paste was applied instead to cover the wound. The patient was just into the surgical treatment in the wound healed after six days.

Mesenteric inflammatory pseudotumor: A difficult diagnosis. Case report

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Inflammatory pseudotumor is a very rare benign neoplasm.

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Definitive diagnosis is usually made only after surgery.

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Mesenteric location is rare.

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Surgical resection can cure the disease.

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Close follow-up is advised to identify recurrences.

Introduction

Inflammatory pseudotumor (IP) is an uncommon benign neoplasm. It was first described in the lung but it has been recognized in several somatic and visceral locations. Mesenteric presentation is rare and its clinical presentation is variable but patients can be completely asymptomatic. Complete surgical resection is the only curable treatment. Rational follow-up protocols have not been established yet.

Presentation of case

A 57 years-old man, with no relevant comorbidities and completely asymptomatic, apart from a lump on the right hypochondrium, was submitted to surgical resection of a large mesenteric mass. The preoperative Computed Tomography suggested gastrointestinal stromal tumor as the most probable diagnosis. Definitive histological examination of the completely resected surgical specimen confirmed the diagnosis of IP. The patient has been on follow-up for four years, without no evidence of recurrence.

Discussion

The preoperative diagnosis of IP may be difficult to establish mainly due to the lack of a typical clinical presentation. It is a rare entity, particularly in the adult population. These two aspects make it easier to neglect this entity in the differential diagnosis of an abdominal mass on asymptomatic adults. Although there are no formal guidelines on follow-up, close follow-up seems to be advisable in these patients as recurrence is frequent.

Conclusion

IP should be present as a possible differential diagnosis in an abdominal mass. Complete excision of the lesion can be curable but close follow-up seems to be required.

The cost of seeking an edge: Recurrent renal infarction in setting of recreational use of anabolic steroids

INTRODUCTION

Anabolic-androgenic steroid (AAS) use and testosterone therapy have been well established risk factors for the creation of a pro-thrombotic state, and to precipitate formation of thromboemboli in individuals already predisposed to thrombosis.

CASE REPORT

Here, we present the case of an amateur bodybuilder, with a negative thrombophilia workup, who experienced primary renal infarction while using the AAS trenbolone acetate and testosterone, as well as a subsequent renal infarction while anticoagulated with apixaban.

DISCUSSION

The development of subsequent infarctions in an anticoagulated patient with discontinued recreational steroid use poses a unique situation and challenges the current understanding of a thrombophilic state associated with steroids. The lifetime prevalence of anabolic steroid use is estimated to be 1% in the male population in the United States which is significant.

CONCLUSION

Further understanding and recommendations of appropriate anticoagulant should be further elucidated to appropriately medically manage patients from this confounding social and medical history.

Surgical management of a giant parathyroid adenoma through minimal invasive parathyroidectomy. A case report

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While parathyroid adenomas account for approximately 80% of PHPT cases, they rarely present as giant parathyroid adenomas.

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Preoperative workup diagnosed the patient with PHPT and helped in accurate localization of the hyperactive parathyroid gland.

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Despite the size of the adenoma, it was successfully removed through minimal invasive parathyroidectomy, through a 2 cm incision.

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Post-surgical recovery was uneventful with normalization of parathormone levels and the patient relieved of her symptoms.

Introduction

Primary hyperparathyroidism is a common endocrine disorder mostly associated to parathyroid adenomas. Although those tend to be small in size, rare cases of giant parathyroid adenomas may be present.

Case presentation

A 42 year old female was admitted in our department due to weakness and vague abdominal pain for the past 8 months. Preoperative laboratory exams indicated primary hyperparathyroidism as a cause to her symptomatology, with elevated values of parathormone and normal values of serum calcium. Ultrasound scan and 99 m Tc-MIBI of her cervical region uncovered a giant 3 × 2 cm parathyroid adenoma, located in the lower left thyroid lobe. Despite its size, the gland was successfully removed through implementation of minimal invasive parathyroidectomy. She was uneventfully discharged on the 1st postoperative day.

Discussion

Although a common reason for developing hyperparathyroidism, parathyroid adenomas may rarely present with exaggerated dimensions and weight. Physical examination is usually unremarkable, while patients may present with symptomatology associated with elevated calcium levels. Treatment of this medical condition consists of surgical removal of the pathologic parathyroid gland either by bilateral neck exploration or through minimal invasive parathyroidectomy. Preoperative localization plays an important role in the second case, since the method focuses on resection of a pre-op marked hyperactive parathyroid gland, through a small incision.

Conclusion

Clinicians must be alerted of hyperparathyroidism in patients presenting with calcium associated symptomatology. Diagnosis is straightforward through laboratory exams, while surgery offers the only permanent treatment option.

An unusual case of neurogenic thoracic outlet syndrome

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Lymphatic cyst is an unusual cause of neurogenic thoracic outlet syndrome.

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Only one previous case has been reported till date from the United States.

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Surgery is preferred to sclerotherapy, with higher success rates.

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Combined supraclavicular and transaxillary approach provides excellent exposure.

Introduction

Neurogenic thoracic outlet syndrome (nTOS) is the most common manifestation of thoracic outlet syndrome (TOS), accounting for more than 95% of cases. It is usually caused by cervical ribs, anomalies in the scalene muscle anatomy or post-traumatic inflammatory changes causing compression of the brachial plexus.

Case presentation

: We present an unusual case of nTOS caused by a cystic lymphangioma at the thoracic outlet, with only one case reported previously in the literature. We used a combined supraclavicular and transaxillary approach for complete removal, which resulted in excellent recovery of the patient.

Discussion

Though lymphatic cysts may be commonly encountered in surgical practice, compression causing nTOS is extremely rare. The location of the lymphatic cyst with compression of the brachial plexus may provide a challenge for treatment. Surgical excision is the preferred method of management, with higher success rates than sclerotherapy.

Conclusion

Surgical excision to ensure complete removal of the cyst is recommended. Sclerotherapy may be used in cases where complete excision of the cyst wall may not be possible.

Curative resection for locally advanced sigmoid colon cancer using neoadjuvant chemotherapy with FOLFOX plus panitumumab: A case report

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Systemic or adjuvant chemotherapy is internationally accepted as a standard treatment for patients with metastatic or postoperative colorectal cancer, respectively.

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Moreover, recent studies have demonstrated that preoperative chemotherapy improves the outcome of patients with CRC with liver metastases.

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However, little is known about the effect and safety of preoperative FOLFOX and panitumumab combined chemotherapy for initially unresectable, locally advanced colon cancer without distant metastases.

Introduction

FOLFOX and panitumumab combined chemotherapy plays an important role for metastatic colorectal cancer. However the usefulness of this regimen for neoadjuvant therapy is unclear.

Case report

A 67-year-old man with abdominal pain and pneumaturia was diagnosed with RAS wild-type sigmoid colon cancer with urinary bladder invasion and colovesical fistulas. Because the cancer was considered to be unresectable, a transverse-loop colostomy was performed. Colonoscopy and computed tomography revealed a marked reduction in the size of the primary tumor after six courses of FOLFOX4 (oxaliplatin, leucovorin, and 5-fluorouracil) plus panitumumab. Laparoscopic sigmoidectomy and partial cystectomy were then performed. The pathological findings based on the resected specimen showed almost complete replacement of the tumor by fibrous tissue, with only a few degenerated tumor glands persisting in the submucosa. The patient’s postoperative course was uneventful and he was doing well, without disease recurrence, after 36 months of follow up.

Conclusion

To our knowledge, this is the first report of a successful curative resection in a patient with initially unresectable, locally advanced colorectal cancer who was treated with FOLFOX4 combined with panitumumab.

Mixed corticomedullary adrenal carcinoma - case report: Comparison in features, treatment and prognosis with the other two reported cases

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Adrenal incidetaloma could be mixed tumor, and should be considered in every case.

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Radiological signs play an important rules in differentiate malignant from benign adrenal tumor.

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Complete immunohistochemical study is necessary to confirm pheochromocytoma that presents normally in the clinic.

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Additional reported cases and clinical trials are needed to put more effective treatment plans for Mixed corticomedullary adrenal carcinoma.

Introduction

Adrenal corticomedullary adenoma was reviewed in many cases in PubMed Library, While the coincidence corticomedullary adrenal carcinoma in the same gland was just described in two cases in the medical literature. Our case is the third to be reported and was treated with surgery and adjuvant chemotherapy and followed for two years.

Presentation of case

A 50-year-old man suffered from a mass effect in the left abdominal side. While the laboratory showed a mild elevation in the levels of both serum cortisol and 24 h urine cortisol, radiological images were highly suggested an adrenal malignant tumor without metastasis. At surgery a 22 cm sized mass was completely resected. Immunohistochemical study identified expression of both adrenocortical carcinoma and pheochromocytoma markers.

Discussion

Cases of coincidence corticomedullary tumor have been published in many reviews, cortical and/or medulllary hypersecretion were not always detected preoperatively by biochemical tests.

Mixed corticomedullary carcinoma are exceedingly rare, we came across three reported cases in medical literature, in one case laboratory tests confirmed both cortical and medulla hypersecretion, while the two others detected only cortical hypersecretion. The final diagnosis was always confirmed by immunohistochemical staining.

Conclusion

It could be noted that this is the first comparison of presentation, diagnosis, treatments and follow-up of the three cases of Mixed corticomedullary carcinoma. This could contribute to understanding the behavior and management of this rare malignancy and make it more familiar in clinical practice.

Miescher's cheilitis: Surgical management and long term outcome of an extremely severe case

INTRODUCTION

Miescher's cheilitis is clinically characterized by persistent swelling of the lip(s). Its pathogenesis is still unknown. Histopathologically is characterized by sub-epithelial edema, increased number of dilated lymphatic vessels and an inflammatory infiltrate and/or non-caseating/non- necrotic granulomas. Even if the disorder must be controlled by medical therapy, surgery may be required to treat most severe cases.

PRESENTATION OF THE CASE

We report a 30-year-old man who presented a persistent swelling of both lips since 8 years, previously treated with intralesional steroid and immunosuppressive therapy. Clinical examination did not show facial nerve palsy or other associated conditions. On the base of clinical and histopathological findings, a diagnosis of Miescher's syndrome was made. Patient underwent Conway's reduction cheilopasty repaired with local flaps. At one-year follow-up, the patient does not show local recurrence of the deformity; both oral continence and lip sensation are preserved.

DISCUSSION

Because of its extreme rarity and unknown etiopathogenesis, Miescher's cheilitis receives poor attention and may often remain misdiagnosed. Several medical therapies are proposed, in particular steroids and immunosuppression. Even if medical therapy remains the main treatment, surgery may be required.

CONCLUSION

Satisfactory results have been obtained combining medical therapy and surgical approach.

Formation of ring-shaped lateral meniscus following anterior cruciate ligament reconstruction: A case report

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There were no meniscal anomalies such as discoid meniscus and ring-shaped meniscus at the first surgery.

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Postoperative MRI showed a ring-shaped lateral meniscus.

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On second-look arthroscopy, there was a meniscus-like tissue formation that connected the anterior horn to the posterior horn of the lateral meniscus at the lateral intercondylar tubercle.

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The ring-shaped meniscus-like tissue was spontaneously formed after ACL reconstruction.

Introduction

We presented the first case in the literature of inter-horn bridge formation involved in ring-shaped lateral meniscus after anterior cruciate ligament (ACL) reconstruction.

Presentation of case

A 22-year-old man underwent anatomic double-bundle ACL reconstruction using semitendinosus tendon autograft. At the surgery, the lateral meniscus showed a normal appearance without meniscal tears and had no instability. There were no meniscal anomalies such as discoid meniscus and ring-shaped meniscus. Magnetic resonance image examination was performed before second-look arthroscopy at 1 year postoperatively. A coronal plane showed a small triangular fragment located at the medial border of the lateral tibial plateau. An axial plane demonstrated a ring-shaped lateral meniscus. On second-look arthroscopy, there was a meniscus-like tissue formation that connected the anterior horn to the posterior horn of the lateral meniscus at the lateral intercondylar tubercle.

Discussion

Ring-shaped meniscus is an extremely rare malformation of the meniscus. Our hypothesis was that drilling debris and remaining remnant of ACL might induce a scar tissue formation.

Conclusion

This is the first case in the literature of inter-horn bridge formation involved in ring-shaped lateral meniscus following ACL reconstruction.

Synovial chondroma in Hoffa's fat pad: Case report and literature review of a rare disorder

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Synovial chrondroma is a rare condition of which the aetiology remains unclear. Large palpable lesions represent an atypical presentation.

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The diagnosis is often not immediately apparent. However it is usually suggested by radiologic investigation and confirmed on histology.

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Disease recurrence is not infrequent after excision (15–23%) and patients should be counselled regarding this.

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Malignant transformation whilst uncommon has been described. At present no definite criteria exist in order to make the diagnosis of malignancy.

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Due to the above risks of recurrence and malignancy, long term follow up of affected patients is advised.

Introduction

Synovial chrondomatosis is a rare disorder characterised by the development of hyaline cartilage from the synovial membrane. Large isolated lesions in the Hoffa's fat pad are an uncommon entity.

Presentation of case

A 33 year old gentleman presented complaining of progressive knee pain associated with an enlarging lesion on the anterior aspect of the right knee, with associated locking and giving way. Examination revealed a firm 4 × 5 cm lesion adjacent to the patellar tendon.

Subsequent CT and MRI demonstrated a lesion in the inferior aspect of Hoffa’s fat pad, with a second lesion adjacent to the proximal tibiofibular joint, in addition to advanced degenerative changes and a meniscal tear.

He proceeded to excisional biopsy. Histological analysis was consistent with a solitary synovial osteochondroma. There were no atypical features suggestive of malignancy.

Discussion

Synovial chondromatosis is a rare disorder affecting the synovial joints. The underlying pathophysiology is thought to be metaplastic change of the synovium to hyaline cartilaginous tissue. Transformation to malignancy has been described but is uncommon with an estimated risk of 5%. It is 1.5–2 times as prevalent in males versus females. Symptoms which patients may complain of include pain;locking and giving way; and palpable masses.

The management usually entails removal of the mass lesion with or without accompanying synovectomy. Recurrence of disease may occur in up to 15–23% of patients.

Conclusion

Synovial chrondromatosis is a rare but well recognised condition. Long term follow up is advised in view of the risk of recurrence and malignant transformation.

Young woman with nutcracker syndrome without main clinic manifestation: Hematuria-Case report

INTRODUCTION

The nutcracker syndrome occurs due to the compression of the left renal vein between the aorta and the superior mesenteric artery. The diagnosis of the syndrome is often difficult and under diagnosed. The main clinical manifestations are hematuria and pelvic or back pain.

PRESENTATION OF CASE

A 25 years old female patient with severe abdominal pain in the lower abdomen without hematuria. Diagnosis with nutcracker syndrome after performing computed tomography. Presented the first episode of pain with 17 years old and was diagnosed at age 25.

DISCUSSION

In the nutcracker syndrome anatomical changes do not generate specific symptoms, causing the disease to be underdiagnosed. In this syndrome, there is increased pressure on the left renal vein, generating several signs and symptoms, and hematuria is one of present. Our patient did not have hematuria. Because of common symptoms, it makes nutcracker syndrome difficult diagnosis, confusing with other diseases, especially with nephrolithiasis. It is usually diagnosed after exclusion of other diseases.

CONCLUSION

The diagnosis of nutcracker syndrome is done after exclusion of other causes of chronic pelvic pain. In most cases, macroscopic and microscopic hematuria are present but was unobserved in this case. Making it more difficult diagnosis.

Roux-en-Y duodenojejunostomy for surgical management of isolated duodenal obstruction due to chronic pancreatitis

INTRODUCTION

Duodenal obstruction in case of chronic pancreatitis is a very rare occurrence and usually presents with gastric outlet obstruction. These cases sometimes require surgical intervention when conservative treatment fails. Gastrojejunostomy and vagotomy has conventionally been performed for management of these cases.

PRESENTATION OF CASE

In this report, we present two cases of isolated duodenal obstruction due to chronic pancreatitis that were managed with Roux-en-Y duodenojejunostomy. All the patients had uneventful post-operative recovery and remained symptom free up to two years of follow up.

DISCUSSION

The isolated duodenal obstruction in chronic pancreatitis is very rare occurring due to fibrotic scarring following pancreatic inflammation an irreversible phenomenon requiring drainage procedure. The advantage of performing Roux-en-Y duodenojejunostomy in these cases is that it avoids complications of gastrojejunostomy such as bile reflux and stomal ulcerations.

CONCLUSION

Roux-en-Y duodenojejunostomy should be considered as an alternative procedure when duodenal obstruction occurs beyond second part of duodenum.

Treatment of intimal sarcoma of peripheral veins

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Intimal sarcoma is an extremely rare group.

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Intimal sarcoma of large veins even rarer information and case reports are limited.

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Unique case in the medical literature and the best current evidence in the biological behavior and the response of the multiple options of treatment in this type of tumors.

Introduction

Intimal sarcoma is an extremely rare group of undifferentiated pleomorphic sarcoma arising from the intimal layer of vessels accounting for only 1% of all sarcomas, intimal sarcoma of large veins are even less common.

Cases presentation

We present two cases of intima sarcoma, one originated form the basilar vein and the other from the cephalic vein, the first one was treated with surgery and postoperative chemotherapy followed by Radiotherapy (RT), the second case was treated with isolated limb perfusion followed by marginal resection and RT. Both patients progressed to the lungs in a short time, the first case was treated with metastasectomy of the lung and is without evidence of disease 7 months after surgery; the second case treated with isolated limb perfusion has stable disease.

Discussion

Intimal sarcoma are very aggressive tumors, with a high metastatic potential, the two patients progressed to lung in a short time (2 months) after local treatment. Both cases exhibit good response to chemotherapy and metastasectomy with a disease – free period of 7 months.

Conclusion

We propose that given the aggressive behavior of these tumors, they should be treated with chemoradiotherapy postoperative, either by systemic chemotherapy or isolated limb perfusion for the limp sparing surgery in this histology.

Case report of ovary and fallopian tube as content of a Spigelian hernia - a rare entity

INTRODUCTION

Spigelian hernia is a rare entity, comprising 1-2% of all hernias. Various abdominopelvic viscera herniate through the defect in the Spigelian fascia and become incarcerated. Specifically in females, the ovary and/or the fallopian tube can herniate through this defect. This is the third reported case of such a hernia.

PRESENTATION OF CASE

We report here a young lady aged 30 years with right-sided ovarian Spigelian hernia. She presented with a painful lump in the right lower quadrant of abdomen for 2 weeks. On examination, she had a tender irreducible lump below and to the right lateral to the umblilicus. CECT revealed a right-sided ovarian Spigelian hernia. The finding was confirmed at exploration and herniorrhaphy performed. She was discharged on the 3rd postoperative day.

DISCUSSION

Diagnosing Spigelian hernia clinically is challenging but radiologic investigations like computed tomography help establish the diagnosis and clarify the contents.

CONCLUSION

Spigelian hernia itself is a rare entity and to add to that, herniation of ovary and fallopian tube through Spigelian fascial defect is very rare and a possibility in females.

Neuroendocrine tumor of the small intestine diagnosed with trans-abdominal ultrasonography: A case report

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Tumors of the small intestine are rare.

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We report a case of neuroendocrine tumor of the small intestine.

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Ultrasonography is useful in the diagnosis of small-intestine neuroendocrine tumor.

Introduction

Tumors of the small intestine are rare. In addition, clinical symptoms are nonspecific and neoplasm-related symptoms occur late. We report a case of neuroendocrine tumor (NET) of the small intestine that was diagnosed early with trans-abdominal ultrasonography (US).

Presentation of case

The patient was a 61-year-old man. Abdominal contrast-enhanced computed tomography (CT) was performed because the patient complained of abdominal pain. The CT showed a tumor lesion in the mesentery. Trans-abdominal US was undertaken to evaluate this tumor lesion, and a tumor lesion of the small intestine was found nearby. A diagnosis of lymph-node metastasis of a small-intestine tumor was made as a preoperative diagnosis. A laparotomy was performed with partial resection of the ileum, together with the small-intestine mesentery including an enlarged lymph node. Histological examination revealed NET of the ileum and lymph-node metastasis.

Discussion

With the application of trans-abdominal US, we could diagnose lymph-node metastasis of a small-intestine tumor relatively early and before surgery.

Conclusion

Trans-abdominal US is useful in the diagnosis of small-intestine NET.

Giant cell tumor of soft tissues: A case report of extra-articular diffuse-type giant cell tumor of the quadriceps

INTRODUCTION

Giant cell tumors of soft tissue (GCTs) are a relatively rare entity. It is a distinct but uncommon group of neoplasms morphologically identical to osseous giant cell tumor. The diffuse type of extra-articular GCT arising within muscle is a rare benign soft tissue tumor with a wide spectrum of clinical presentation.

PRESENTATION OF CASE

This article reports a rare case of a 44-year-old woman with a mass arising from her right thigh. MRI showed only a few areas of low T2 signal in a mass that was hyper intense to muscle. Histopathology of this lesion located within the right quadriceps muscle revealed admixture of multinucleated giant cell with mononuclear cells. This patient was treated by surgical resection and followed up for recurrence.

DISCUSSION

Diffuse-type GCTs are commonly located in the periarticular soft tissues, but on rare occasions these lesions can be purely intramuscular or subcutaneous and can be challenging to diagnose. Characteristic findings include gradient echo secondary to hemosiderin deposition, and the low signal on T2.

CONCLUSION

Because extra-articular diffuse-type GCTs are rare, the differential diagnosis is challenging. The clinical outcomes of diffuse-type GCTs are unclear because of their rarity. Benign clinical course is expected if the lesion is excised adequately.

Case report of a giant colonic sigmoid diverticulum causing sigmoid volvulus

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Giant colonic diverticulum is a rare complication of colonic diverticulosis that occurs when a single diverticulum enlarges to over 4 cm in diameter.

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The author presents a rare case of a giant colonic diverticulum that presented as a sigmoid volvulus. The management and pathology are discussed.

Introduction

Giant colonic diverticulum is a rare complication of colonic diverticulosis that occurs when a single diverticulum enlarges to over 4 cm in diameter. There have been fewer than 200 cases reported worldwide since it was first described in 1946.

Presentation of case

The author presents a rare case of a giant colonic diverticulum that presented as a sigmoid volvulus. The patient underwent emergency surgery with resection of the diverticulum and reduction of the volvulus.

Discussion

Due to their propensity to cause complications and mechanical blockage from their large size, all authors recommend surgical resection of giant colonic diverticula. This has been documented to be safely done by diverticulectomy as was performed in this patient, but also by segmental colectomy, laparoscopic diverticulectomy, or laparoscopic colectomy.

Conclusion

Giant colonic diverticulum is a rare entity that tends to cause many intra-abdominal complications, including volvulus. Surgical resection is recommended once identified.

Deep peroneal nerve palsy due to osteochondroma arising from fibular head and proximal lateral tibia

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Osteochondroma are the most common benign tumors.

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Disease affecting knee joint in 94% of all cases.

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Clinicians should be aware of the possible tumoral lesions in drop foot etiology.

Following median and ulnar nerves, peroneal nerve entrapment is the most frequent nerve involvement in the body Katirji and Wilbourn (1998) [1].

Osteochondromas are the most common benign bone tumors comprising 9% of all bone tumors and 35% of benign bone tumors Porter (2000) [2].

Hereditary exostoses (HME) is an autosomal dominant disorder with variable penetrance characterized by multiple osteochondromas near joints. It is one of the most commonskeletal dysplasias with a frequency of about 1.18%.

In this study, we aimed to present a case with a drop foot resulting from osteochondromas of proximal tibia and fibula and help to guide the clinicians in differential diagnosis according to SCARE criteria Agha (2016) [3].

Bakri balloon placement in the successful management of postpartum hemorrhage in a bicornuate uterus: A case report

•

This is the first reported case of successful use of Bakri balloon placement in the presence of postpartum hemorrhage in a bicornuate uterus.

•

Physicians should be aware that uterine malformation is not a contraindication to Bakri balloon placement.

•

When performing Bakri balloon placement in the presence of uterine malformation, efforts be made to precisely locate the site of bleeding.

Introduction

Postpartum hemorrhage is an obstetric emergency that accounts for 25% of maternal deaths worldwide. Initial management consists of uterotonic administration but in cases in which there is a failure of response to medication, uterine cavity tamponade can be effective. This is the first reported case of successful Bakri balloon placement in the management of postpartum hemorrhage at the time of cesarean delivery in a patient with a bicornuate uterus.

Presentation of case

The patient was a primigravid female who presented at 40 weeks and 1 day gestation with known bicornuate uterus and findings suggestive of placental abruption. Labor was subsequently induced and magnesium was administered after a diagnosis of preeclampsia with severe features was made. Cesarean delivery was then performed for category II fetal heart rate tracing remote from delivery. Intraoperative course was significant for uterine atony unresponsive to oxytocin, carboprost, methylergonovine and misoprostol administration. The right uterine horn was noted to be markedly atonic compared to the left. A Bakri balloon was then placed transvaginally and inflated with 600 mL of saline in this location. Atony then resolved.

Discussion

Although uterine malformation is not a documented contraindication to Bakri balloon placement, there is no literature on its efficacy in the treatment of hemorrhage in the presence of this anomaly.

Conclusion

In the management of postpartum hemorrhage, Bakri balloon placement is associated with success in the presence of a bicornuate uterus. Care should be taken to direct insertion of the balloon in the appropriate location.

Pyoderma Gangrenosum of the breast: A case report study

•

Pyoderma gangrenosum of the breast as a de novo presentation is rare and mostly associated with underlying autoimmune or hematologic disorders.

•

It is also associated with breast cosmetic surgery or previous cesarian section.

•

In this study, we report a case of pyoderma gangrenosum of the breast in a patient with no prior medical history and no surgeries.

•

Treatment of pyoderma gangrenosum of the breast consists of systematic corticosterod use, while surgical debridement has a beneficiary effect.

Introduction

Pyoderma gangrenosum (PG) of the breast is a rare and rapidly spreading disease, which usually co-exists with severe underlying systemic conditions. PG often presents secondary to breast surgery with skin lesions and signs of infection, even though it is a non-infectious, necrotizing dermatological entity.

Presentation of case

We present a case of de novo unilateral breast PG in 37-year-old woman, with a clear medical history whatsoever. The patient was treated with corticosteroids and, in a two-month follow up, presents with nearly no signs of PG.

Discussion

PG of the breast presents with atypical clinical signs and is characterized by an exclusion-based diagnosis. It often mimics inflammation but is resistant to antibiotics.

Conclusion

The optimal treatment for PG is systemic use of corticosteroids and surgical debridement of the necrotic tissue, while the timely onset of the therapeutic approach is of outmost importance.

Warfarin associated venous limb gangrene in cancer-related DVT (case report)

•

Extensive thrombosis, absent/contraindicated thrombolysis, inefficient conservative treatment – encourage venous clot removal.

•

Venous thrombectomy, with fasciotomy and delayed necrectomy, may be considered for limb salvage in selected acute cases.

•

Due to high chances of severe post-thrombotic morbidity, ileofemoral phlegmasia patients may benefit the most from timely venous thrombectomy.

Introduction

Warfarin anticoagulation of oncologic patients with DVT may paradoxically progress to phlegmasia cerulea dolens and limb gangrene, due to cancer-associated disseminated intravascular coagulation. This case report, written in line with the SCARE criteria, endorses venous thrombectomy in selected patients to attempt limb salvage. A young woman’s warfarin associated acute ileofemoral phlegmasia that developed over cervical cancer radiation therapy induced DVT, was successfully resolved by clot removal. Extracting venous thrombus at the onset, while still as unorganized masses, preserves ambulation and prevents post-thrombotic syndrome development, an improvement of quality of life especially significant for oncologic patients with limited life-expectancy.

Presentation of case

A 34 years old female, with history of stage 3 cervical cancer following radiation therapy, was admitted in regards to left lower limb painful pitting oedema with cramps. Doppler scan revealed a left ileofemoral DVT. She was set on LMWH, but on fourth day of warfarin co-administration, phlegmasia cerulea dolens developed. An emergency venous thrombectomy with fasciotomy was performed. Postoperatively, dry foot gangrene developed, which dictated transmetatarsal amputation. The patient was discharged after 2 months of inpatient treatment, preserving ambulation.

Discussion

Venous thrombectomy (with fasciotomy) in oncologic phlegmasia, ± serial debridement, becomes an attractive opportunity for limb salvage when feasible at acute presentation, available in a limited resource setting.

Conclusion

Due to severe procoagulant/anticoagulant balance disturbances in cancer patients’ warfarin-bridged for DVT, phlegmasia onset should not defer surgical approach, unless a rapid response to conservative treatment.

Acute abdomen in a patient with paraesophageal hernia, resulting in acute compromised respiratory function: A case report

INTRODUCTION

We present a case of acute abdomen, causing increased intra-abdominal pressure, leading to further herniation of an existing paraesophageal hernia, and consequently acute compromised respiratory function. This acute respiratory complication to a paraesophageal hernia has not previously been reported.

PRESENTATION OF CASE

We present a case of a 75-year-old female who was acutely admitted with stridor. The patient was known to have a paraesophageal hernia monitored using watchful waiting, and dyspnoea. The patient's condition deteriorated, leading to intubation. Diagnostic imaging revealed a paraesophageal hernia pressing onto the trachea as well as appendicitis and ileus. Surgery confirmed perforated appendicitis, peritonitis, and ileus causing high intra-abdominal pressure, resulting in further herniation of the paraesophageal hernia as a cause for acute compromised respiratory function. Appendectomy and gastropexy were performed. The patient was later discharged to rehabilitation.

DISCUSSION

Patients with pulmonary symptoms caused by a paraesophageal hernia, especially patients with sizeable hernias, could potentially be in greater risk of severe airway affection if complicated by acute abdomen. These patients could benefit from elective hernia repair, rather than watchful waiting, as it would eliminate pulmonary symptoms and prevent similar cases. Patients monitored using watchful waiting should be informed that acute abdomen could cause acute compromised respiratory function.

CONCLUSION

Any case of acute abdomen causing high intra-abdominal pressure could potentially cause further herniation of an existing paraesophageal hernia, resulting in acute compromised respiratory function. In patients known to have a paraesophageal hernia, similar cases should be suspected if the patient presents with acute breathing difficulties.

Left-sided gallbladder (Sinistroposition) encountered during laparoscopic cholecystectomy: A rare case report and review of the literature

•

LSG is a peculiar anatomical variation that is difficult to be identified preoperatively.

•

LSG is associated with anatomical anomalies that may lead to intra-operative injuries.

•

Safe laparoscopic cholecystectomy is feasible by placing the patient to left-side up position for better exposure of the operative field.

Introduction

True Left-sided gallbladder (LSG) is a rare anatomical variation with a prevalence of 0.3%. Mainly discovered during the operation, its surgical approach in the laparoscopic setting may be challenging even for an experienced surgeon.

Presentation of case

LSG was unexpectedly discovered in a young man during laparoscopic cholecystectomy. There were no pre-operative indications of this sinistroposition. The laparoscopic cholecystectomy was performed with minor surgical modifications and it was uneventful. A meticulous review of recent literature about LSGs was conducted as well.

Discussion

LSG is a scarce anatomical aberration that is difficultly identified pre-operatively. Surgeons should be aware of this aberration and of its accompanying anatomical variations in order to perform a safe laparoscopic cholecystectomy.

Conclusion

Surgeons, by placing the patient to left-side up position, are able to expose the Calot’s triangle and possible accompanying anatomical anomalies and thus perform a safe laparoscopic cholecystectomy without difficult surgical modifications.

A case report of primary necrotising fasciitis of the breast: A rare but deadly entity requiring rapid surgical management

•

Primary necrotising fasciitis of the breast is an extremely rare entity.

•

We present the youngest patient described in the literature.

•

Prompt resuscitation and surgical intervention are critical to successful management.

Introduction

Necrotising fasciitis of the breast is a rare entity with very few cases reported in the literature. It is rapidly progressive and can lead to sepsis and multi-organ failure without prompt medical and surgical management.

Presentation of case

We describe a case of a non-diabetic 23-year-old female with primary necrotising fasciitis of the right breast. She presented in septic shock with gross breast discolouration and nipple discharge. Immediate resuscitation followed by muscle-sparing mastectomy within 3 h of her presentation was performed. She was managed postoperatively in intensive care. Complications included myocardial infarction and anuria requiring continuous renal replacement therapy. She eventually recovered with close to normal cardiac function and was discharged home after skin grafting of her mastectomy wound.

Conclusion

This is the youngest patient with primary necrotising fasciitis of the breast described in the literature. Prompt resuscitation and an aggressive surgical approach are critical to the successful management of this life threatening pathology.

A first reported case of metastatic anorectal amelanotic melanoma with a marked response to anti-PD-1 antibody nivolumab: A case report

•

We report a first case of nivolumab reduction of metastatic anorectal amelanotic melanoma (AAMM).

•

Multimodal therapy including nivolumab will be effective also for non-cutaneous AAMM.

Introduction

Anorectal amelanotic melanoma (AAMM) is a rare disease with poor prognosis. A standard treatment strategy for AAMM has not been established.

Presentation of case

We report a case of successful treatment of AAMM with nivolumab. A 67-year-old man was referred for colonoscopy which revealed type I tumor in the rectum. AAMM was diagnosed with immunostaining histopathological biopsy findings. Enhanced computed tomography (ECT) revealed the rectal tumor without distant organ metastasis. We performed laparoscopy-assisted abdominoperineal resection. ECT at three months after surgery revealed liver metastases and right ischial bone metastasis. Although we had started dacarbazine monotherapy, black spots that were suspicious of skin metastases had appeared on systemic skin. Therefore, we started nivolumab therapy. ECT at 3 months after initiation of nivolumab showed shrinkage of liver metastasis. We have continued strict follow-up every 2 months and checked no oncologic progression at 17 months after initiation of nivolumab.

Discussion

The anti-PD-1 antibody have improved prognosis of malignant melanoma. However, there are no reports of nivolumab for treatment of AAMM.

Conclusions

Our patient is the first reported case of AAMM treated with nivolumab. We consider that nivolumab will be effective for non-cutaneous malignant melanoma.

Laparoscopic diagnosis and repair of Spigelian hernia: A case report and literature review

INTRODUCTION

Spigelian hernias are a rare type of hernia which protrude through the abdominal wall at the semilunar line. They are especially difficult to diagnose due to their location and non-specific symptoms and are often overlooked because of their positioning between muscular layers. Patients may present with localized pain which can aid the diagnosis. CT and ultrasound are also helpful.

PRESENTATION OF CASE

We present the case of a 75-year-old female patient who presented to Hialeah Hospital with a one-year history of abdominal pain localized to the left lower quadrant.

DISCUSSION

A Spigelian hernia containing omentum, was found during a diagnostic laparoscopy. The hernia was reduced, and the abdominal defect was repaired via primary repair, reinforced by mesh. The patient recovered uneventfully.

CONCLUSION

Nonspecific physical exam findings and inconclusive imaging studies represented a diagnostic challenge. Here we discuss a case of a Spigelian hernia discovered through diagnostic laparoscopy.

Incarcerated incisional hernia of the sigmoid colon after appendectomy: A case report

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Incisional hernia after appendectomy is rare because the incision is small.

•

Small bowel and omentum are commonly herniated through the weak abdominal wall.

•

Incisional hernia of the colon after appendectomy is extremely rare.

•

Computed tomography is a useful diagnostic tool for differentiating unusual abdominal wall mass.

Introduction

Incisional hernia after appendectomy is rare, affecting 0.4% to 0.9% of cases. The small bowel and omentum are commonly herniated through the abdominal wall defect, but incisional hernia of the sigmoid colon is extremely rare.

Case presentation

A 78-year-old man presented with a right lower quadrant abdominal wall mass on the previous McBurney incision site. He had a history of appendectomy for appendicitis 40 years ago. Computed tomography (CT) showed the sigmoid colon herniated thorough the abdominal wall defect. During the operation, a feces-impacted sigmoid colon was found protruding through the defect of the abdominal wall. Reduction of the sigmoid colon into the peritoneal cavity and herniorrhaphy with primary repair were performed.

Discussion

The ascending and descending colon are fixed into the retroperitoneum, whereas the transverse and sigmoid colon are not, which can allow these bowel segments to herniate through a weak abdominal wall just as small bowel loops do. However, incisional hernia of the colon is extremely rare. The diagnosis of incisional hernia can be easily made because a reducible abdominal wall mass can be detected by physical examination. In cases with rare type of hernia, CT can identify unusual types of abdominal hernias and differentiate hernias from neoplasms, inflammatory disease, and hematoma.

Conclusion

Although incisional hernia of the colon after appendectomy is extremely rare and preoperative diagnosis by physical examination is difficult, CT is a useful method to make the correct diagnosis, avoiding unnecessary invasive intervention, particularly in patients with an unusual abdominal wall mass.

Cervicovaginal agenesis treated with modified Yang-Monti technique in two steps: Case report and literature review

INTRODUCTION

Müllerian duct anomalies are rare with less than 200 cases published in the literature. Recently, the implementation of the Yang-Monti principle for the creation of the neovagina has been used in 10 previous published cases. Here, we report the first case of cervicovaginal agenesis treated with the modified Yang-Monti technique in two steps in México.

PRESENTATION OF CASE

A 14-year-old female presented to the pediatric consult with a history of primary amenorrhea and a chronic-cyclic pelvic pain. She had normal external genitalia and secondary sexual characteristics, with a small vaginal pouch. Pelvic ultrasonography and magnetic resonance showed the absence of cervix and proximal vagina. The surgical approach was carried out in two steps. In the first, a neovagina was created with the modified Yang-Monti technique. On a second step one year after, the neovaginal dome was anastomosed with the uterus in a diamond shape, using Gore-tex^® in the cervicovaginal anastomosis, and a Foley catheter to prevent stenosis. After an 18-month follow-up, no complications have been observed. She has been taking Drospirenone and Ethinyl Estradiol with regular menstrual cycles.

DISCUSSION

The surgical treatment of cervicovaginal agenesis has evolved. The advantages of the modified Yang-Monti technique lie in the possible diminution of the tension on the vascular pedicle, and the gained length of the neovagina. To perform this procedure in two steps, likely diminishes the risk of neovaginal ischemia and leakage of the anastomosis.

CONCLUSION

The two-steps modified Yang-Monti technique represents a safe alternative for the management of cervicovaginal agenesis.

Duodenal gangliocytic paraganglioma, successfully treated by local surgical excision-a case report

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Duodenal gangliocytic paraganglioma is a rare tumor usually with benign behavior.

•

Resection of the tumor, either endoscopically or surgically is the treatment of choice.

•

Complete removal of the mass offers cure and long-term survival.

Introduction

Duodenal gangliocytic paragangliomas are rare neoplasms often arising in proximity to the major duodenal papilla of Vater. These neoplasms are considered to have a benign behavior with lymph node metastases being a rare phenomenon and distant metastatic disease even more so. Resection of the tumor is the only definitive therapy.

Presentation of case

A 67 year old male presented to a referring hospital with symptoms of fatigue and malaise. Evaluation with CT imaging revealed a 3.1 cm intraluminal mass situated grossly at the junction of the third with the fourth portion of the duodenum. The tumor was found to be situated near the ampulla of Vater and was excised through a longitudinal duodenotomy followed by myotomy of the sphincter of Oddi.

Discussion

Complete resection of duodenal gangliocytic paragangliomas by surgical or endoscopic means is the only potential cure. Endoscopic removal is the first option and is both safe and adequate. Ηowever, localized excision may be utilized instead in those cases in which endoscopic removal is not possible or cannot achieve negative margins. Recurrent disease after complete resection is unlikely.

Conclusion

Cases of duodenal gangliocytic paragangliomas are best managed with endoscopic resection. However, local surgical excision remains as a second-choice procedure. Adjuvant chemotherapy and radiotherapy are unnecessary after complete excision.

Traumatic tension pneumocephalus: Two case reports

INTRODUCTION

Traumatic pneumocephalus rarely evolves into tension pneumocephalus. It can be devastating if not recognized and treated promptly.

CASE PRESENTATION

We presented two cases of post-traumatic tension pneumocephalus. A 30- year old male pedestrian hit by a car presented with right frontal bone fracture extending to right frontal sinuses. He developed pneumocephalus involving all ventricles and subdural space and extending down to foramen magnum with tight basal cistern. The patient was managed conservatively. During the hospital course, he developed cerebrospinal fluid leak from the facial fractures and meningitis. After complete recovery, the patient was discharged home in a good health condition. The second case was a 43- year old lady driver who involved in a motor vehicle crash and presented with comminuted fracture of the right frontal bone, right parietal extra-axial hemorrhage. She developed pnemocephalus involving the bilateral frontal lobes, mainly on the left side with extension to the left lateral ventricle. Pneumocephalus was also noted in the pre-pontine cistern. The patient had rhinorrhea during the hospital course. The patient underwent wound debridement, intracranial pressure monitoring, and repair of her globe and advancement flap for right facial injury.

CONCLUSIONS

These are two rare cases with posttraumatic tension pneumocephalus treated conservatively with a favorable outcome. Early diagnosis of tension pneumocephalus is a crucial step to facilitate early recovery; however, the associated injuries need attention as they could influence the hospital course.

Pancreatitis, panniculitis and polyarthritis (PPP-) syndrome caused by post-pancreatitis pseudocyst with mesenteric fistula. Diagnosis and successful surgical treatment. Case report and review of literature

INTRODUCTION

Pancreatitis, panniculitis and polyarthritis syndrome is a very rare extra-pancreatic complication of pancreatic diseases.

PRESENTATION OF CASE

While in most cases this syndrome is caused by acute or chronic pancreatitis, we report a case of a 62-year-old man presenting with extensive intraosseous fat necrosis, polyarthritis and panniculitis caused by a post-pancreatitis pseudocyst with a fistula to the superior mesenteric vein and extremely high blood levels of lipase. This became symptomatic 2.5 years after an episode of acute pancreatitis and as in most cases abdominal symptoms were absent. Treatment by surgical resection of the pancreatic head with the pseudocyst and mesenteric fistula led to complete remission of all symptoms.

DISCUSSION

A review of the literature revealed that all publications are limited to case reports. Most authors hypothesize that an unspecific damage can cause a secretion of pancreatic enzymes to the bloodstream leading to a systemic lipolysis and fat tissue necrosis, especially of subcutaneous tissue, bone marrow, inducing panniculitis, polyarthritis and osteonecrosis. Even if caused by an acute pancreatitis abdominal symptoms are often mild or absent in most cases leading to misdiagnosis and poor prognosis.

CONCLUSION

While symptomatic treatment with NSAR and cortisone showed poor to moderate response, causal treatment can be successful depending on the underlying pancreatic disease.

Gastric duplication cyst (gdc) associated with ectopic pancreas: Case report and review of the literature

Introduction

Duplication of the alimentary tract is a relatively rare congenital anomaly. It can affect any part of the gastrointestinal tract, with ileum being the most common site. These malformations are believed to be congenital, formed before the differentiation of epithelial lining, and therefore named for the organ with which they are associated. Duplication cysts of the stomach represent four percent of all alimentary tract duplications.

Case report

Here, we report a rare case of symptomatic duplication cyst of stomach associated with ectopic pancreas presenting in adult.

Discussion

Gastrointestinal duplication is a relatively rare anomaly that may occur at any level from oral cavity to rectum with ileum being the most common site. Duplication cysts of the stomach are quite rare, and most of them have been reported in children. Duplication cysts of ileum are usually located on the mesenteric border, whereas the usual location for gastric duplication cysts is along the greater curvature. The duplication cyst is entirely separated from the adjacent bowel but shares a common wall. Complete removal is the treatment choice to avoid the risk of possible complications such as obstruction, torsion, perforation, hemorrhage, and malignancy. A non-communicating GDC is classically treated by complete excision of the cyst and resection of the shared wall between stomach and the duplication cyst.

Conclusion

This unusual developmental anomaly should be included in the differential diagnosis of cystic masses of the gastrointestinal tract, and the possibility of malignancy should also be considered, so as be treated surgically by complete resection.

Totally extra-peritoneal repair for acute incarcerated femoral hernia with intestinal obstruction

INTRODUCTION

Femoral hernias frequently present with incarceration, resulting in obstruction and strangulation. Laparoscopic groin hernia repairs have been shown in the elective setting to be an effective alternative to open repair. Acute incarceration of groin hernia with obstruction, though previously seen as a relative contraindication, has been increasingly repaired with minimally invasive techniques, with the potential benefit of avoiding the morbidity associated with a laparotomy.

PRESENTATION OF CASE AND DISCUSSION

We describe a case of an acutely incarcerated femoral hernia with intestinal obstruction that was repaired using the totally extra-peritoneal approach. A releasing incision was performed to facilitate reduction of hernia prior to mesh repair. Diagnostic laparoscopy through a separate incision was then performed.

CONCLUSION

This modification of the TEP repair technique for the acutely incarcerated and obstructed femoral hernia serves to minimise potential contamination by keeping the pre-peritoneal plane strictly separate from the intra-peritoneal space.

Horizontal traumatic laceration of the pancreas head: A rare case report

INTRODUCTION

This case report is intended to inform acute care surgeons about treating rare horizontal laceration of the pancreas head caused by blunt trauma.

CASE PRESENTATION

A 57-year-old woman who sustained blunt abdominal trauma during a car crash was transported to the emergency center of our hospital with unstable vital signs due to hemorrhagic shock. Computed tomography showed transection of the pancreas head and massive intra-abdominal hemorrhage. She was referred for emergency surgery because of a transient response. Laparotomy at five hours after the accident initially revealed consistent massive bleeding from branches of the superior mesenteric artery and vein, which we resolved by suturing the vessels without damaging the main trunks. A horizontal laceration and complete transection of the pancreatic head were then confirmed but the main pancreatic duct remained intact. The lower part of the pancreatic head including the uncus with the attached part of the duodenum was resected, and the pancreatic stump remaining after transection was fixed by suturing. The jejunal limb was attached to the remnant duodenum by side-to-side functional anastomosis. Although gastric emptying was delayed for one month after surgery, the postoperative course was good and the patient recovered at three months thereafter. The embryonic border of pancreas head accompanied with pancreatic divisum was considered for this laceration without disruption of the main pancreatic duct.

DISCUSSION

Blunt pancreatic trauma usually causes vertical transection and thus, horizontal transection is considered rare. The embryological anatomical border between the ventral and dorsal pancreas due to pancreatic divisum was supposed to be transected and therefore the main pancreatic duct was not damaged.

CONCLUSION

Hemorrhagic shock and rare pancreatic head trauma were treated by appropriate intraoperative management.

Aberrant subvesical bile ducts identified during laparoscopic cholecystectomy: A rare case report and review of the literature

•

Aberrant subvesical bile ducts are a rare anatomical variation defined as a network of bile ducts located in the peri-hepatic tissue of the gallbladder fossa.

•

Their injury is almost inevitable and it leads to bile leakage, which is a life-threatening complication of laparoscopic cholecystectomy.

•

Meticulous operative technique and detailed exposure of the operative field is the cornerstone of a safe laparoscopic cholecystectomy, when surgeons encounter this rare anatomical variation.

Introduction

Aberrant subvesical bile ducts are a scarce anatomical variation, consisted by a network of bile ducts located in the peri-hepatic capsule of the gallbladder fossa. These rare ducts are usually discovered intraoperatively and their presence poses the risk of bile injury and clinically significant bile leak.

Presentation of case

Aberrant subvesical bile ducts were unexpectedly identified in a young woman during laparoscopic cholecystectomy. These three ducts were clipped carefully for avoidance of bile duct injury and subsequent bile leak. The operation was uneventful. A meticulous review of the recent literature was conducted as well.

Discussion

This unusual anatomical variation of the biliary tract is mainly discovered during the operation. Thus, surgical injury of these ducts is nearly inevitable and it provokes the severe complication of bile leak. Bile injury represents the most crucial and life-threatening postoperative complication of cholecystectomies. Surgeons in the right upper quadrant of the abdomen should be constantly aware of this rare anatomical variation.

Conclusion

Aberrant subvesical bile ducts are associated with a high risk of surgical bile duct injury. Nevertheless, meticulous operative technique combined with surgeons’ perpetual awareness concerning this peculiar anatomical aberration leads to a safe laparoscopic cholecystectomy.

Surgical management of malignant bowel obstruction in recurrent pancreatic cancer

•

Palliative surgery should be considered in recurrent pancreatic cancer patients.

•

Surgery for malignant bowel obstruction may have a positive impact in select patients.

Introduction

Malignant bowel obstruction (MBO) is harrowing complication of gastrointestinal cancers. Only a few studies have reported on the surgical roles of bowel obstruction from recurrent pancreatic cancer. We report successfully management for malignant bowel obstruction by palliative surgery for relief of symptoms.

Presentation of case

A 43 year old man was diagnosed with pancreatic tail cancer. After distal pancreatectomy, he underwent six cycle of adjuvant chemotherapy. 10 months later, he had suffered from small bowel obstruction by seeding metastases. We performed segmental small bowel resection. This patient had good recovery and continued to receive palliative chemotherapy. A 78 year old man was diagnosed with unresectable, huge pancreatic cancer. He had recurrent obstructive symptoms and periumbilical pain. We decided palliative surgery of wide excision of umbilical abdominal mass for pain control. 3 weeks later, he presented with recurrent symptoms in previous op site. We planned 2nd operation for relief of symptoms. He underwent surgery to resect abdominal wall mass and small bowel due to 2 cm sized mass in terminal ileum. After 2nd surgery, he received consistently palliative chemotherapy with good clinical condition.

Discussion and conclusion

Palliative surgery improves quality of life in recurrent pancreatic cancer patients and can continue patient’s palliative management. In selected patients, palliative surgery may effective management for progress of survival and quality of life.

A case report of the clear cell variant of gallbladder carcinoma

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Patient history and clinical findings are often not specific enough to arrive at a diagnosis of clear cell gallbladder carcinoma.

•

Consideration of morphologic and immunophenotypic features are essential to establish a diagnosis of clear cell gallbladder carcinoma.

•

It is important for clinicians to differentiate gallbladder cancer from metastases that most commonly arise from the kidneys and other possible secondary foci.

Introduction

Clear cell gallbladder carcinoma accounts for less than 1% of all gallbladder malignancies and demonstrates its unique histopathological characteristics in patients with no prior medical illness or familial predisposition.

Presentation of case

Here we present a case of a 56-year-old female, with no prior medical conditions presented with a 2-month history of upper abdominal pain. Routine hematological and biochemical tests were unremarkable. An abdominal ultrasound revealed the presence of a gallbladder calculi, and a fundic mass while magnetic resonance cholangiopancreatography revealed a 8.0 cm × 3.5 cm gallbladder mass. Computed tomography imaging excluded any distant haematogenous metastases. An open cholecystectomy with lymphadenectomy was proceeded by staging laparoscopy. Upon pathologic investigation, the morphologic and immunophenotypic features supported a diagnosis of clear cell variant of gallbladder carcinoma.

Discussion

Pathological prognostications for primary clear cell gall bladder carcinomas are not well defined due to the rarity of cases and possible misidentification as secondary metastases. Foci of adenocarcinoma within the tumor along with immunohistochemical staining probes can be informative in consideration of differential diagnosis.

Conclusion

In these cases, clinical case management should be personalized for increased survival with the possible incorporation of next generation sequencing approaches to guide therapeutic algorithms. We discuss this exceedingly rare case of the clear cell variant of gallbladder carcinoma in detail, highlighting some of the diagnostic, and clinical challenges.

Bowel obstruction secondary to an ectopic pancreas in the small bowels: About 2 cases

•

2 cases of intestinal obstruction secondary to ectopic pancreas.

•

Ectopic pancreas causing intestinal occlusion is a very rare entity.

•

In the first case, the ectopic tissue caused mechanical luminal occlusion in the distal ileal part, whereas the 2nd case presented intussusception sign, 20 cm distal to the Treitz ligament.

•

Ectopic pancreas can serve as a lead point for ileo-ileal intussusception.

Introduction

Ectopic pancreas is most commonly found in the jejunum and stomach. Most patients remain asymptomatic, and the diagnosis is usually made at autopsy or incidentally. We report here 2 cases of intestinal occlusion, secondary to an ectopic pancreatic tissue. Both cases were managed successfully by laparoscopy and laparotomy with subsequent segmental intestinal resection.

Case presentations

Case 1 – An elderly patient presented to the ER because of intestinal occlusion. Paraclinical investigations were consistent with occlusion, with ileal suffering signs on CT-scan. After laparotomy and segmental intestinal resection were done, histopathalogy showed evidence of ectopic pancreas obstructing the intestinal lumen. Case 2 – A young man presented to the ER with acute onset of epigastric pain. signs of peritoneal irritation. Ct-scan showed evidence of small bowel intussusception. Exploratory laparoscopy was done, and confirmed the diagnosis. The intussusceptum was at the level of the proximal jejunum. The suffering intestinal part was exteriorized and then resected. Histopathology was consistent with an ectopic pancreas.

Discussion

Symptomatic ectopic pancreas is extremely rare. Symptoms may include, bleeding, intestinal occlusion and intussusception. Few similar cases have been reported in the literature, and the current ones are to be added.

Conclusion

As mentioned above, ectopic pancreatic tissue rarely causes symptoms. We presented 2 cases that presented 2 possible complications secondary to this pathology. Both cases were managed successfully.

A rare case of jejunogastric intussusception following gastric surgery

•

Jejunogastric intussusception is an extremely rare complication of gastric surgery.

•

Longest interval from the initial gastric surgery for gastric cancer to be reported.

•

Fewer than 200 cases have been reported so far.

•

It could be afferent, efferent or mixed type.

•

High index of suspicion needed to diagnose this potentially fatal condition.

Introduction

Jejunogastric intussusception (JGI) is an extremely rare complication of prior gastric surgery. Fewer than 200 cases have been reported in the literature.

Case presentation

We present a case of an elderly male who presented with typical abdominal pain, hematemesis and a palpable epigastric mass. Ultrasonography and upper endoscopy diagnosed jejunogastric intussusception. Emergent laparotomy with manual reduction of the efferent loop intussusception resulted in successful treatment.

Discussion

We report this case of efferent loop JGI, developing 40 years after the primary Billroth II gastrectomy. This is the longest interval from the initial gastric surgery for gastric cancer to be reported.

Conclusion

Maintaining a high index of suspicion is paramount in early diagnosis and treatment of this condition, which is associated with high mortality rates if surgery is delayed.

A rare cause for Hartmann's procedure due to biliary stent migration: A case report

•

Migration of a biliary stent can cause life-threatening complications.

•

When a stent migration occurs, in case of complications, surgical removal is the only treatment option.

•

Among the complications associated with stent migration, intestinal bleeding, obstruction and perforation are of outmost importance.

Introduction

Biliary stent migration (proximal or distal) occurs in 6% of all cases. The majority of these migrating stents are passing through the intestine, without causing any complications. Usually when a stent migration occurs, endoscopic retrieval is the proper treatment option, except in case of complications when surgical removal is the only treatment option. This report presents a case of a biliary stent which migrated and caused a sigmoid colon perforation.

Presentation of case

A 75 years old female patient presented to the emergency department with diffuse abdominal pain, nausea and vomiting. Clinical examination showed distended abdomen and signs of peritoneal irritation.

CT scan of the abdomen revealed free gas and fluid in the left iliac fossa, as well as a foreign body penetrating the sigmoid colon. Emergency laparotomy was performed. A plastic stent was found perforating the sigmoid colon through a diverticulum. The rest of the sigmoid colon was intact presenting only uncomplicated diverticula. Hartmann’s operation was performed, involving the diseased segment, together with part of the descending colon due to profound diverticulosis. Patient’s post-surgical course was uneventful and was discharged on postoperative day 10.

Discussion

Migration of a biliary stent can cause life-threatening complications such as perforation of the intestine and peritonitis. The migration of the stent from the biliary tree may be mostly asymptomatic except in cases of intestinal perforation that immediate surgery is the proper treatment option. On the other hand, even in cases of benign lesions of the bile duct, the stent should be removed immediately after dislocation in order to reduce the risk of secondary complications such as obstruction, infection or perforation.

Conclusion

In cases of non-complicated stent migration endoscopic retrieval is the indicated treatment. In patients who suffer serious complications due to stent dislocation, emergency surgery may be the proper treatment option.

Revisional bariatric surgery in a transplant patient

INTRODUCTION

A BMI of over 35-45kg/m2 is deemed the upper limit for considering a patient for a renal transplant. Voluntary weight loss attempts are a major concern for patients while on hemodialysis, however, bariatric surgeries have opened up a new door to notable weight loss results, even demonstrating significant improvements of patients' diabetic profile and hypertension.

CASE REPORT

Case of a 52-year-old male with a BMI of 42 in end-stage renal disease, that needed a kidney transplant but was ineligible to be placed on the waiting list due to his weight. A laparoscopic sleeve gastrectomy (LSG) was performed to aid with his weight loss. He also showed major improvements in his hypertension and diabetes profiles. The patient started gaining weight as well as showing deterioration in his diabetic control. He underwent the renal transplant 1.5 years post LSG, after which he showed improvements in his blood results, diabetic and hypertensive control. However, his weight began to increase again, for which he underwent gastric bypass. Since then, the patients' glucose, BUN and creatinine have normalized and his weight continued to drop, reaching a BMI of 31.83kg/m2 2 years post bypass.

CONCLUSION

Bariatric surgery is a safe and effective procedure to assist renal transplant patients in losing weight. In addition, it has proven to be effective in the management of the co-morbidities that are associated with renal failure. Our study was also able to prove that converting form an SG to a bypass in a transplant patient is a safe and feasible option.

Huge echinococcal cyst of the liver managed by hepatectomy: Report of two cases

INTRODUCTION

Echinococcocal cysts are predominantly located in the right liver. They are usually solitary and asymptomatic, but large cysts can cause compression symptoms.

CASE REPORTS

We report two cases of huge (25cm and 20cm in diameter, respectively) echinococcal cysts located in the left liver, which presented as a large palpable mass causing compression symptoms. Diagnosis was established with CT scan showing a cystic mass with the characteristic daughter cysts and reactive layer (pericystic wall) consisting of fibrous connective tissue and calcifications. Both patients were treated radically with left hepatectomy and had uneventful postoperative course and no recurrence upon follow-up.

DISCUSSION

The treatment of liver echinococcal cysts represent a unique surgical challenge. Even though conservative approaches are less technically demanding, the radical approach with resection has better outcome with less recurrences, when performed by experienced surgeons.

CONCLUSION

Resection rather than drainage is the management of choice for such huge liver echinococcal cysts.

Concurrent hyphema and orbital apex syndrome following herpes zoster ophthalmicus in a middle aged lady

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Herpes zoster ophthalmicus is an uncommon clinical presentation.

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Concurrent hyphema and orbital apex syndrome are rare clinical sequelae.

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Hyphema is postulated due to auto immune vasculitis affecting iris vessel.

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Orbital apex syndrome results from occlusive vasculitis affecting vasculature of optic nerve and extraocular muscles.

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This incidence probably suggests that occlusive vasculitis occurs at more than one site in the affected dermatome.

Introduction

Hyphema and orbital apex syndrome occurring concurrently in a patient with herpes zoster ophthalmicus have not been reported previously. We present a case with these unique findings and discuss the pathogenesis of these conditions and their management.

Presentation of case

A 59-year-old Malay lady with underlying diabetes mellitus presented with manifestations of zoster ophthalmicus in the left eye. Two weeks later, she developed total hyphema, and complete ophthalmoplegia suggestive of orbital apex syndrome. She was treated with combination of intravenous acyclovir and oral corticosteroids, and regained full recovery of ocular motility. Total hyphema persisted, and she required surgical intervention.

Discussion

Hyphema is postulated to occur due to an immune vasculitis affecting the iris vessels. Orbital apex syndrome is probably due to an occlusive vasculitis affecting the vasculature of the extraocular muscles and optic nerve, resulting from a direct invasion by varicella zoster virus or infiltration of perivascular inflammatory cells. Magnetic Resonance Imaging of the brain is essential to exclude possibility of local causes at the orbital apex area.

Conclusion

Herpes zoster ophthalmicus is an uncommon ocular presentation. Managing two concurrent complications; persistent total hyphema and orbital apex syndrome is a challenging clinical situation. Early diagnosis and prompt treatment are essential to prevent potential blinding situation.

Intraneural ganglion cyst of the ulnar nerve in an unusual location: A case report

INTRODUCTION

Intraneural ganglion cysts are benign, mucinous, non-neoplastic lesions of the peripheral nerves. While the most common location of intraneural ganglion cysts is the ulnar nerve and its branches, intraneural ganglion cyst involving the superficial branch of the ulnar nerve has not yet been reported.

PRESENTATION OF CASE

A-25-year-old woman presented with pain and a palpable mass in the hypothenar region of the volar side of her right hand. Her neuromuscular examination was normal. The pain was unresponsive to nonsurgical treatments. After confirming with imaging modalities, the initial diagnosis was considered as an intraneural ganglion cyst arising from superficial ulnar nerve. Excision of the ganglion and exploration of the articular branch (if seen in operation) decision was undertaken by the senior author. Whether MRI or intraoperative exploration, not identified an articular branch.

DISCUSSION

Intraneural ganglion cysts of peripheral nerves may be seen in miscellaneous locations in the body. However, to our knowledge, an intraneural ganglion cyst involving the superficial branch of the ulnar nerve is unique. While a variety of theories have been proposed to enlighten the etiopathogenesis of intraneural ganglia, the latest and most affirmed is the unifying articular (synovial) theory.

CONCLUSION

Intraneural ganglion cysts may be seen on the hypothenar side of the palm. The etiology and treatment of choice are closely associated with each other in this rare disorder. It is important to realize a related articular branch, otherwise the origin of cyst formation remains, and this may cause other para-articular cysts.